Health Policy And Planning[JOURNAL]
Sun
200 papers
Partial pictures: what routine health data can and cannot tell us about the quality of maternal and neonatal health services in Tanzania.
Molenaar J, Kikula A, Julius Z … +4 more , Hanson C, van Olmen J, Pembe AB, Beňová L
Health Policy Plan · 2026 May · PMID 41789676 · Full text
Measurement of contact coverage of maternal and newborn health services may overestimate the benefits of the care that is provided, because the quality of care is not captured. It is therefore important to better underst...
Measurement of contact coverage of maternal and newborn health services may overestimate the benefits of the care that is provided, because the quality of care is not captured. It is therefore important to better understand the opportunities and challenges of capturing elements of care quality in routine health information systems (RHIS). This study explored healthcare workers' (HCWs), health sector managers' and policymakers' perspectives on the value and limits of routine health data to understand the quality of maternal and neonatal health services in Tanzania. We conducted qualitative research during two periods to capture perspectives across facility, district, regional and national levels. In Mtwara region in 2023, we conducted ethnographic observations at two hospital labour wards and 29 in-depth interviews with healthcare workers, hospital leaders, and district/regional managers. In 2025, we carried out 17 additional interviews with regional managers in Mtwara and with key national-level stakeholders. Our findings demonstrate that Tanzania's RHIS provides a valuable but partial picture of quality of care for maternal and neonatal health services. Care processes-including both provision and experience of care-are captured only to a limited extent. Using boundary object theory, we highlight how the same health information must serve diverse stakeholder needs. While there are opportunities to integrate more quality-of-care indicators, standardized RHIS cannot be expected to comprehensively capture the multifaceted nature of care quality. For quality measurement to support meaningful local health service improvement, a flexible, bottom-up approach is essential. However, the current emphasis on top-down oversight acts as a barrier for local-level data use. Relevant and feasible measurement of the quality of facility-based care requires a fundamental shift in current RHIS priorities-from systems that extract data for those 'up there' to platforms that also create value for those who provide care.
Conditional cash incentives, community health workers, and continuum of maternal and child healthcare: evidence from India.
Mishra N, Vellakkal S
Health Policy Plan · 2026 Apr · PMID 41773900 · Full text
Continuum of care in maternal and child health (MCH) services is a key strategy for improving MCH outcomes. This study examines the effect of conditional cash incentives and community health worker support on the uptake...
Continuum of care in maternal and child health (MCH) services is a key strategy for improving MCH outcomes. This study examines the effect of conditional cash incentives and community health worker support on the uptake of the continuum of MCH care, defined as the sequential utilization of antenatal, skilled delivery, and postnatal services. Using nationally representative cross-sectional datasets and a difference-in-difference framework, we find that both interventions significantly improved the continuum of MCH care. The intent-to-treat estimates showed a 5-percentage-point increase in the proportion of women completing the full continuum of care. Heterogeneity analysis revealed more substantial effects among educated women, those in urban areas, and those in higher wealth quintiles. Insights from qualitative interviews with mothers and community health workers suggested that awareness of antenatal care and institutional delivery increased; however, postnatal care was typically sought only in response to complications, and the uptake of all recommended MCH services as a full continuum was often hindered by intersecting demand- and supply-side barriers. Notably, participants emphasized that sustained community health worker engagement had a more significant impact on ensuring care continuity than cash incentives alone. These findings highlight the need for policy strategies that enhance community health worker-led support mechanisms, combined with financial incentives, to promote the comprehensive and sustained use of maternal health services among disadvantaged population groups.
Integration of complementary and alternative medicine in the Indian health system: how the state inadvertently undermines policy implementation.
Patel G, Brosnan C, Taylor A
Health Policy Plan · 2026 Apr · PMID 41766287 · Full text
India's AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) integration policy emphasizes medical pluralism. However, implementation occurs within a complex health system where the state apparatus, thro...
India's AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) integration policy emphasizes medical pluralism. However, implementation occurs within a complex health system where the state apparatus, through its governance and policy processes, affects health services and outcomes. This study explores how state and policy complexities shape AYUSH integration processes and practitioners' capacities in primary healthcare. Qualitative research was conducted in an eastern Indian state and involved observations (19 days) and interviews (37) with AYUSH doctors, biomedical doctors, nurses, pharmacists, and administrators. Thematic analysis enabled identification of themes. State-level employment rules placed AYUSH doctors on low-paid, short-term rolling contracts, but the effects of this marginalized position were intensified by irregular AYUSH medicine supplies and shared governance between two directorates. Governance of integrative facilities and AYUSH medicine stock-outs shifted practice patterns towards biomedical treatments by AYUSH doctors to keep health services functioning, which increased biomedicine demand and further narrowed the scope of AYUSH in a self-reinforcing cycle. Inter-departmental collaboration between the directorates was fragmented, lacking accountability and prioritization of AYUSH integration activities. Limitations in AYUSH medicines and the absence of promotional campaigns narrowed the scope of AYUSH services and facilitated the 'biomedicalization' of AYUSH integration. Local governance bodies offered occasional support, but their involvement was neither formalized nor consistent. Thus, integration processes emerged not from linear policy structures but from feedback mechanisms in which changes in policy priorities at the state and district levels produced disproportionate effects on AYUSH integration, demonstrating a system responsive to resource and information flows. Achieving medical pluralism will require adaptive governance: setting iterative integration targets, establishing cross-directorate collaboration and learning platforms, and increasing the resource independence of AYUSH.
Effect of continuity of care on medical expenditures for hypertensive patients in high-altitude areas of China.
Zhong S, Jia C, Chen W … +4 more , Yang Q, Chen J, Xiao W, Ye T
Health Policy Plan · 2026 Apr · PMID 41746832 · Full text
Managing hypertension is particularly challenging in high-altitude regions of China due to chronic hypoxia and limited healthcare access. Continuity of care has been proposed as a cost-effective approach, yet its economi...
Managing hypertension is particularly challenging in high-altitude regions of China due to chronic hypoxia and limited healthcare access. Continuity of care has been proposed as a cost-effective approach, yet its economic impact in this context remains unclear. Using basic medical insurance claims data from 11 823 hypertensive patients in three high-altitude cities (January 2022-December 2023), this study examined the association between continuity of care and medical expenditures. A generalized linear model with a log link function was employed to analyze total medical costs, while a Tobit regression model was used to assess out-of-pocket (OOP) costs. Heterogeneity was analyzed based on sex, insurance type, and ethnic groups. If the Bice-Boxerman Continuity of Care Index (COC) were maximized, hypertensive patients could experience a 15.63% reduction in total medical costs and 25.92% in OOP costs. If the Usual Provider of Care Index (UPC) were maximized, total medical costs and OOP costs could decrease by 18.94% and 31.61%, respectively. Heterogeneity analysis indicated that both COC and UPC were negatively associated with OOP costs across sex and insurance types, but significant associations with total medical costs were mainly observed among Tibetan patients, females, and those enrolled in Urban and Rural Resident Basic Medical Insurance. Higher continuity of care was significantly associated with lower medical expenditures for hypertensive patients residing in high-altitude areas; however, the magnitude of this beneficial effect varied considerably across different population subgroups. These heterogeneous effects suggest that interventions designed to enhance care continuity may need to be tailored to specific patient demographics. Therefore, future prospective studies or policy interventions are warranted to validate these findings.
Multi-actor collaborations in primary health care implementation: a Social Network Analysis of the primary health care strategy in Ghana.
Gadeka DD, Akweongo P, Aryeetey GC … +3 more , Whyle EB, Aheto JMK, Gilson L
Health Policy Plan · 2026 Apr · PMID 41744218 · Full text
Bottom-up theory demonstrates that networks of actors play important roles in policy implementation, yet limited attention has so far been paid to the influence that actor networks might have on the implementation of pri...
Bottom-up theory demonstrates that networks of actors play important roles in policy implementation, yet limited attention has so far been paid to the influence that actor networks might have on the implementation of primary health care (PHC) strategies and outcomes. This study examined the roles actor networks play in the implementation of Community-based Health Planning and Services (CHPS) in Ghana, focusing on the nature and patterns of relations and structure and strength of prevailing collaborations. This was a cross-sectional study using a social network analysis methodology in eight districts across two regions in Ghana. The study population was implementers of CHPS from the community, district, regional, national, and development partners. Data were obtained using a modified pretested closed-ended social network questionnaire. To establish collaborative relationships, knowledge of other actors and the degree of communication on issues related to CHPS implementation were surveyed. Data were analysed using Gephi software version 0.9.2. The analysis demonstrated existing actor networks of Community Health Committees (CHCs), Community Health Officers (CHOs), Community Health Volunteers (CHVs), Sub-district, and district-level networks, including local government actors and political leaders, as well as regional, national, and development partner actors in CHPS implementation. The nature of relations showed isolated networks of CHCs, CHVs, and sub-districts across both regions. Patterns of interactions revealed that CHO networks collaborate with each other, while CHCs primarily collaborate with CHOs. Overall, weak collaborative relationships were noted among the actor networks (network density <10%). The results suggest segmented, decentralized networks with limited involvement of critical actors, including community-level, local government, political leaders, national-level, and development partners in CHPS implementation. The network analysis highlights weak collaborative relationships among actor networks in CHPS implementation, a practice which negatively impacts its implementation experience. The study highlights pathway to strengthen cohesion and improve collaborative relationships in addressing CHPS as a PHC strategy.
Understanding what factors influence community health worker involvement in hypertension service delivery in Kenya: applying a community health system lens.
Kagwanja N, Oyando R, Hassan S … +11 more , Diallo BA, Badjie J, Lucinde R, Mumba N, Kinyanjui S, Perel P, Etyang A, Aaliyan N, Leli H, Nolte E, Tsofa B
Health Policy Plan · 2026 Apr · PMID 41735613 · Full text
The systematic involvement of community health workers (CHWs) in hypertension management can improve outcomes and achieve blood pressure control. However, much of this evidence is from effectiveness trials conducted unde...
The systematic involvement of community health workers (CHWs) in hypertension management can improve outcomes and achieve blood pressure control. However, much of this evidence is from effectiveness trials conducted under ideal conditions, with little evidence from programmes operating in routine conditions. In Kenya, recent policy changes have expanded CHW roles to routinely incorporate non-communicable disease (including hypertension) service delivery. We undertook an exploratory descriptive qualitative study in one county, examining what CHWs now referred to as community health promoters (CHPs) do in relation to hypertension service delivery, influences on their involvement, and considerations for sustainability. We found ad hoc and fragmented CHP involvement in practice despite policy guidance for community-level hypertension service delivery. Drawing on the extended health systems building blocks framework, we identified multiple capacities that can support expanded CHP roles in hypertension care, including the pre-existing community health service structure and societal partnerships, as well as their level of motivation. Policy provisions for CHP professionalization (payment of stipends, provision of CHP kits with varied commodities and training) create an enabling environment. However, sustained adoption of the new CHP roles may be impeded by (i) challenges in meeting the financial and supply chain obligations for stipend payments and commodities, respectively; and (ii) inadequate sensitization of communities and frontline-providers concerning expanded CHP roles and implications for facility-level hypertension care. To effectively implement recent policies, strengthening coordination and communication across all community and health system actors is needed, as well as clarity and deliberation on long-term financing for the community health system.
Community care policy at the intersection of HIV and unemployment crises in South Africa: paradoxes and paradigms.
van Ryneveld M, Schneider H
Health Policy Plan · 2026 May · PMID 41718486 · Full text
The community care sector is a major component of social protection systems in South Africa. However, despite considerable investment and policy attention on social protection in South Africa, the community care sector c...
The community care sector is a major component of social protection systems in South Africa. However, despite considerable investment and policy attention on social protection in South Africa, the community care sector continues to face enormous challenges and pressures. On the one hand, government invests a significant amount in social spending and aims to honour its constitutional responsibilities towards improving the health and social welfare of the country. On the other hand, community-based care workers are socially and economically marginalised, and community care services remain fragmented and often inaccessible to those who need them most. This paper explores how elements of South African policy on the community care sector emerged historically out of policy responses to parallel social crises of HIV/AIDS and unemployment in the period 2000-10. We draw on the theories of John Kingdon (agenda setting) and Nancy Fraser (needs interpretation) as the lenses to analyse data from policy documents, published literature, and key informant interviews. We show the convergence and consolidation of policies across sectors in the study period into a community care sector characterised by competing and unresolved tensions: between constitutional promises of social and economic rights and enduring conceptualisations of social reproductive labour as feminised, devalued, and 'invisibilised' within the private, domestic sphere. This results in a community care sector that has limited effectiveness as an arm of the social protection system, and which continues to be plagued by the structural inequalities that characterise South African society.
Dynamic and heterogeneous impacts of granting and revoking elective c-section rights in São Paulo.
Cordeiro G, Gonçalves J, Lagarde M
Health Policy Plan · 2026 Apr · PMID 41701623 · Full text
Elective caesarean sections (c-sections) present a significant public health challenge due to associated health risks and increased costs. This study examines the causal impacts of a unique natural experiment in São Paul...
Elective caesarean sections (c-sections) present a significant public health challenge due to associated health risks and increased costs. This study examines the causal impacts of a unique natural experiment in São Paulo, Brazil: Law 17,137/2019, which temporarily allowed pregnant women to opt for c-sections in public healthcare facilities. Using a difference-in-differences estimator, we analyse the Law's effects on c-section rates across various hospital types, municipal characteristics, and demographics. The Law led to a significant and immediate 3.03% point increase in c-section rates in public hospitals. Notably, this effect was limited to the public sector, with no consistent changes observed in private or mixed facilities. The impact was also temporary; following the Law's revocation less than a year later, c-section rates promptly reverted to pre-enactment levels, indicating no lasting effects. We find no evidence that the Law shifted deliveries from paid private care to free public hospitals. Our analysis reveals heterogeneous impacts, with the largest increases in c-section rates occurring in municipalities that had lower baseline c-section rates, a greater reliance on public healthcare, and fewer healthcare resources. These findings suggest that the law disproportionately affected areas with greater public health system strain. Interestingly, the increase in c-sections primarily occurred among low-risk births and had no detectable effect on newborn health outcomes, such as birth weight or Apgar scores. The additional 4500 c-sections performed under the law created an added fiscal burden of approximately R$459 000 for the public health system, based on the cost difference between vaginal and c-section deliveries. This study underscores that while granting elective choice may seem empowering, it can lead to a surge in unnecessary, costly, and riskier procedures, highlighting the crucial need to consider both equity and resource implications when designing healthcare policies.
Advancing health policy and systems research and analysis: new frontiers, renewed relevance.
Kwamie A, Gilson L, Compaore R … +10 more , Cloete K, El-Jardali F, Shekh Mohamed I, Molyneux S, Ramani S, Schneider H, Srinivas PN, Tomson G, Tsofa B, Rasanathan K
Health Policy Plan · 2026 Mar · PMID 41701510 · Full text
Health systems are at a crossroads. Globally, health systems are straining under the weight of responding to persistent and emergent challenges. Uncertainties in health financing, service delivery, new technologies and d...
Health systems are at a crossroads. Globally, health systems are straining under the weight of responding to persistent and emergent challenges. Uncertainties in health financing, service delivery, new technologies and disease burdens are hindering health systems abilities to maximize collective and scaled action to achieve health equity and social justice. In March 2025, a group of health policy and systems experts were convened by an organization, to consider the 'new frontiers' of the field in the context of shifting global and national landscapes. Deliberations centred on the critique that health policy and systems research (HPSR) need to restate its core foundations, better articulate its impacts in real health systems and policy processes, while defining its role within or apart from 'global health'. Six frontiers were identified: new institutional forms of HPSR beyond academic settings; more fully theorized and hypothesized studies that go beyond descriptive; more applies systems thinking; new educational models to support analysis, networking and systems leadership; more domestic financing for HPSR; and genuine engagement with a new set of health system development actors. For HPSR to remain relevant, strengthening the science and practice of how diverse actors engage to bring about collective action for health equity and social justice is imperative. The current global geopolitical, financing, and planetary shifts, while critical, present an opportunity for these new frontiers in HPSR to deepen the impact of the field.
Correction to: Governing health through security in the Philippines: a realist analysis.
Health Policy Plan · 2026 Mar · PMID 41701282 · Full text
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Strengthening Data-Driven Primary Health Care Delivery in Rajasthan, India.
Dalal S, Nagar R, Abdullah H … +2 more , Patwa S, Borkan J
Health Policy Plan · 2026 Feb · PMID 41689264 · Publisher ↗
Digital health information systems have the potential to improve data-driven decision-making and strengthen primary health care delivery in low- and middle-income countries (LMICs). This study examines Rajasthan, India's...
Digital health information systems have the potential to improve data-driven decision-making and strengthen primary health care delivery in low- and middle-income countries (LMICs). This study examines Rajasthan, India's public health information systems with an aim to describe data processes and identify key barriers and opportunities for improvement. Using a qualitative approach, we conducted in-depth interviews with 39 stakeholders, including frontline health workers and state health officials. Our findings highlight inefficiencies in parallel paper and digital reporting systems, leading to high health worker burden, redundant data entry, delays in patient care, and poor data accountability. While digital platforms have improved data accessibility and care coordination, challenges such as poor interoperability, IT infrastructure limitations, and gaps in digital literacy remain. Lessons from successful digital health implementations in other LMICs suggest that integrated, human-centered, and interoperable systems are critical for sustainable digital transformation. We propose a "5I Framework" for policymakers to streamline Rajasthan's digital health ecosystem: (1) Integrated platforms, (2) Implementable systems co-designed with health workers, (3) Ink-free transitions away from paper-based systems, (4) Insights from geospatial and real-time data, and (5) Incentives aligned with workforce needs. Strengthening Rajasthan's digital health systems through these strategies can enhance service delivery, improve public health outcomes, and serve as a model for other LMICs.
Expert stakeholders on the role of qualitative research in World Health Organisation guidelines.
Taylor M, Garner P, Oliver S … +1 more , Desmond N
Health Policy Plan · 2026 Mar · PMID 41670470 · Full text
Qualitative research findings are sometimes used in guideline development, but usually in an ad hoc manner. We sought to explore how qualitative research could contribute to guideline development, identify examples of qu...
Qualitative research findings are sometimes used in guideline development, but usually in an ad hoc manner. We sought to explore how qualitative research could contribute to guideline development, identify examples of qualitative research being used to inform guideline development, and gather suggestions for how qualitative research might be incorporated more systematically in guideline development. Using a topic guide, in 2022-24, we interviewed experts who had participated in World Health Organization (WHO) guideline development. We used purposeful sampling, including qualitative researchers, guideline developers, guideline panel members, and implementation researchers. We interviewed 16 participants, and identified three themes: (i) respondents endorsed using qualitative research findings in developing WHO guidelines, and highlighted examples where this approach had been useful; (ii) recommendation questions in the guideline process are built on clinical decision-making, which can sometimes be too detached from social contexts for broader health problems; (iii) using qualitative research findings to help delineate context has a greater potential role in guidelines. We interpret these findings to indicate that qualitative research could be used more systematically, particularly to inform a broader framing of a health problem, or later in recommendations, to tailor to particular contexts.
How much can healthier diets reduce future economic and human costs? Results from Ethiopia and the Philippines.
Horton S, Gaffey MF, Dizon F … +6 more , Ferrer E, Golloso-Gubat MJ, Hanley-Cook G, Nacionales K, Okamura KS, Fracassi P
Health Policy Plan · 2026 Apr · PMID 41668443 · Full text
As countries progress through the 'nutrition transition' and experience rising rates of obesity and noncommunicable disease, concern has broadened from a primary focus on economic consequences of child stunting, to incor...
As countries progress through the 'nutrition transition' and experience rising rates of obesity and noncommunicable disease, concern has broadened from a primary focus on economic consequences of child stunting, to incorporate multiple forms of malnutrition, including overweight and obesity, or a more ambitious set of individual dietary risk factors from the Global Burden of Disease work. This paper conceptualizes a methodology that uses unhealthy diets to better understand the economic impact as the nutrition transition progresses. The Lives Saved Tool (LiST) is used to estimate how much healthier diets alone (without other health interventions) can reduce future child stunting. The Global Burden of Disease Results Tool is used to estimate how much healthier diets can reduce future noncommunicable disease among adults, via effects on three metabolic markers (high body mass index -BMI, high systolic blood pressure, and high fasting blood glucose). We then link the metabolic markers to diet quality (measured by the Global Diet Quality Score). Calculations are made for the Philippines for 2014 and 2021 and Ethiopia for 2011 and 2019. Recent studies have estimated the present value of future child stunting costs as 2.0% of GDP for the Philippines and 5.25% for Ethiopia, in both cases in 2023, of which we estimate up to 45% and 50%, respectively, are avertible over the long run by healthier diets, while public nutrition and public health programs account for the rest. The present value of costs associated with the three metabolic markers among adults is estimated as 7.99% of GDP (Philippines 2021) and 2.15% (Ethiopia 2019), of which we estimate 20% is avertible by healthier diets. The total losses avertible by healthier diets are therefore estimated as 2.5% of GDP (Philippines 2021) and 3.1% (Ethiopia 2019), with metabolic factors predominating in the Philippines and stunting in Ethiopia.
The economic cost of outpatient primary care of adults with multimorbidity (HIV, diabetes, and hypertension) in rural South Africa.
Holden CC, Mdewa W, Mathema T … +10 more , Kabudula CW, Adetunji K, Zent R, Goldstein S, Glover K, Hazelhurst S, Klipin M, Tollman S, Gómez-Olivé FX, Thsehla E
Health Policy Plan · 2026 Apr · PMID 41666164 · Full text
Sub-Saharan Africa (SSA) is experiencing an epidemiological transition where non-communicable diseases are becoming the leading cause of disability and mortality alongside infectious diseases such as HIV/AIDS. Multimorbi...
Sub-Saharan Africa (SSA) is experiencing an epidemiological transition where non-communicable diseases are becoming the leading cause of disability and mortality alongside infectious diseases such as HIV/AIDS. Multimorbidity, the coexistence of two or more long-term conditions, is increasing in SSA. However, the cost of managing multimorbidity is largely unknown. This study aimed to estimate the economic cost of public outpatient primary care for adults with multimorbidity (HIV, hypertension, and/or diabetes, and their associated conditions: cardiovascular disease, and TB) in rural South Africa. This study used a cross-sectional, retrospective cost-of-illness approach to estimate the direct and indirect costs of multimorbidity management in Bushbuckridge, Mpumalanga, in 2022. Data were synthesized from patient-level data from eight public primary healthcare facilities within the Agincourt study site-a rapidly transitioning rural South African setting. Additionally, government reports and an existing study on transport costs and productivity losses conducted within the Agincourt study site were used to estimate the costs of managing patients in the primary care facilities. Results showed that patients with multimorbidity had higher average economic costs per patient compared to those with single conditions. Overall, patients with multimorbidity increase costs above the baseline of a patient with a single condition (R4 900/annum) by between 42% and 83%. Patients with multimorbidity also incur slightly higher costs associated with accessing primary care services compared to those with a single condition. However, our model shows that the additive cost of managing multiple conditions in separate consultations is higher than managing all conditions in one visit. This shows that managing patients within an integrated care model seems to have a cost-limiting effect. However, treatment guidelines for managing multimorbidity in South Africa should be developed to ensure standardized care.
Understanding the role of 'software' in health system capacity for non-communicable disease response: hypertension care in rural Coastal Kenya.
Oyando R, Kagwanja N, Diallo BA … +10 more , Hassan S, Badjie J, Lucinde R, Mumba N, Kinyanjui SM, Perel P, Etyang A, Barasa E, Nolte E, Tsofa B
Health Policy Plan · 2026 Apr · PMID 41665886 · Full text
Research on health system capacity to manage non-communicable diseases (NCDs) has largely focused on 'system hardware' such as infrastructure, workforce, and commodities. However, this overlooks the critical role of 'sys...
Research on health system capacity to manage non-communicable diseases (NCDs) has largely focused on 'system hardware' such as infrastructure, workforce, and commodities. However, this overlooks the critical role of 'system software' elements, such as relationships, norms, and power, and the complex adaptive nature of health systems. This study aimed to explore how health system hardware and software elements interact to shape the capacity of the health system to deliver hypertension care in Kilifi County in the coastal region of Kenya. We conducted a cross-sectional qualitative study and collected data using document reviews (n = 13) and in-depth interviews with purposively selected front-line health workers (FLHWs) at five health facilities and health managers at county and national levels (n = 37). We applied a framework approach to data analysis, utilizing complex adaptive systems (CAS) theory as our analytic framework. Complex interactions of system hardware and software elements constrained the provision of hypertension care. Frequent medicines stockouts (hardware) stemmed from budgetary gaps, procurement delays, regulatory restrictions, and weak quantification practices (software). To mitigate medicines shortages, facilities employed adaptive responses such as inter-facility borrowing and sourcing from alternative suppliers (software). Access and continuity of care were enabled by organizational norms like dedicated hypertension clinic days (software) but undermined by inadequate consultation rooms, staff shortages (hardware) and limited training and support supervision (software). FLHWs' ideas to improve medication adherence were undermined by staff shortages (hardware) and inadequate support from facility managers (software), weakening service delivery. The application of CAS theory unpacked the hitherto underexplored aspects of health system capacity. System 'software' plays a central role in shaping health system capacity for hypertension care. Therefore, strengthening health system capacity for NCDs requires coordinated investment in both system hardware and software elements. Importantly, system strengthening interventions should consider the CAS nature of health systems to foster conditions for productive emergence.
One size does not fit all: income-sensitive thresholds for catastrophic health expenditure.
Dubey JD, Kumar D, Reddy A B
Health Policy Plan · 2026 Apr · PMID 41649954 · Full text
This study develops an inverse rank-weighted index (IRWI) to adjust catastrophic thresholds for out-of-pocket expenditure (OOPE) components. The proposed method eliminates the arbitrariness of the existing proportionate...
This study develops an inverse rank-weighted index (IRWI) to adjust catastrophic thresholds for out-of-pocket expenditure (OOPE) components. The proposed method eliminates the arbitrariness of the existing proportionate approach by ensuring fairness in determining component-specific catastrophic thresholds. It measures the effective expenditure share of each OOPE component while considering the concentration of component-specific spending across household income levels. Using nationally representative household survey data on healthcare consumption from 2017-8, the study estimates catastrophic health expenditure (CHE) at both aggregate and component levels in India under uniform, proportionate, and IRWI thresholds. The findings reveal that the uniform threshold significantly underestimates CHE incidence, whereas component-specific thresholds identify twice as many households that experience CHE. Shifting from the proportionate method thresholds to IRWI thresholds significantly alters CHE estimates. The IRWI approach offers a more reliable framework for integrating component-specific and aggregate CHE assessments. It underscores the need for income-sensitive, component-specific thresholds to accurately quantify financial hardship and prevent underestimating healthcare-related economic burden.
Sustaining health systems in sub-Saharan Africa: public-private partnerships in a new era of reduced donor funding.
Haffner R, Rahim FO, Kendall L … +5 more , Ali S, Karthik R, Tamirisa K, Abdelkader M, Bekele A
Health Policy Plan · 2026 Apr · PMID 41640056 · Full text
Recent reductions in US global health funding have disrupted essential programs in sub-Saharan Africa, highlighting the region's vulnerability to external financing shocks. The suspension of the United States Agency for...
Recent reductions in US global health funding have disrupted essential programs in sub-Saharan Africa, highlighting the region's vulnerability to external financing shocks. The suspension of the United States Agency for International Development initiatives has affected disease control, maternal care, and health system operations across 47 countries, raising urgent questions about how to sustain progress without reliable donor support. This commentary examines the potential of public-private partnerships (PPPs)-structured collaborations in which governments and private actors share financing, risk, and managerial responsibility-to strengthen domestic capacity. Drawing on examples from Senegal, Nigeria, and Kenya, we explore how service-, concession-, financing-, and technology-focused PPPs can mobilize additional resources, expand access, and improve service delivery. We also address key challenges, including governance risks, fiscal constraints, and shifting global power dynamics. While not a substitute for aid, well-designed PPPs aligned with national priorities can support more resilient, equitable, and self-reliant health systems in sub-Saharan Africa.
Can co-designing interventions with affected communities help prevent violence against women? Findings from a process evaluation of the E le Saua le Alofa (Love Shouldn't Hurt) pilot in Samoa.
Mannell J, Lowe H, Tanielu H … +5 more , Isaako Hosea E, Tevaga P, Apelu L, Alisi Fesili F, Copas A
Health Policy Plan · 2026 Apr · PMID 41636420 · Full text
There has been increasing interest in co-designing interventions with end users to prevent violence against women (VAW). Co-design is theorized as an ethical approach to research able to engage some of the most marginali...
There has been increasing interest in co-designing interventions with end users to prevent violence against women (VAW). Co-design is theorized as an ethical approach to research able to engage some of the most marginalized groups in VAW prevention. However, there is little evidence of whether co-designing interventions can reduce violence against women, or a theoretical consideration of how it might do so. This paper contributes to current discussions about co-design by examining the results of the E le Saua le Alofa (Love Shouldn't Hurt)-a pilot intervention that engaged Samoan communities in co-designing violence prevention activities. A mixed-methods evaluation of the pilot has shown promising results, and in this paper, we consider how the co-design process may have contributed to these results. The evaluation of the co-design process assessed four theorized mechanisms: (1) increased ownership of the problem of violence; (2) improved health behaviours and social norms; (3) relevance of actions taken to address VAW; (4) addressing power structures arising from coloniality. Our results show that a change in violence outcomes occurred through the pilot's ability to revisit previous conversations about violence in Samoa, prompting new activities by local leaders, and tightening village rules on violence. Yet, the activities implemented by local leaders were largely unpredictable and sometimes conflicted with global evidence. We argue that such actions should not be construed by policymakers as the "unpredictable outcomes" of an intervention, but rather understood within a broader framework of diversified knowledge systems. The need for balance in co-designing VAW interventions with communities affected by violence highlights a key challenge of decolonizing VAW practice within a co-production framework.
Measuring and assessing corruption in public health systems in low- and middle-income countries: a scoping review of methods.
Anderson B, McKee M, Agwu P … +1 more , Balabanova D
Health Policy Plan · 2026 Mar · PMID 41631655 · Full text
Corruption in health systems has serious implications for health outcomes and equitable care. Although various methods exist to measure it, their application, purpose, effectiveness, and context have not yet been systema...
Corruption in health systems has serious implications for health outcomes and equitable care. Although various methods exist to measure it, their application, purpose, effectiveness, and context have not yet been systematically consolidated to enable learning. We conducted a scoping review to identify empirical approaches used to measure health-sector corruption globally, with a focus on low- and middle-income countries. We examined the opportunities and challenges of these methods and developed a typology to guide future research. We searched Econlit, Embase, Global Health, Medline, Social Policy and Practice, Web of Science, and websites of international organisations focused on corruption research. Reference lists of included studies were also hand-searched. Two rounds of searches were conducted: first for studies published between 2000 and 2022, then for earlier publications dating back to 1993. Thirty-seven studies were narratively synthesised. Common methods included surveys, interviews, focus groups, and audits. Surveys were more common before 2000. Ethnography, investigative journalism, co-production, and crowdsourcing-though previously recommended-were rarely used or reported in the literature. Often, measuring corruption was not the primary aim, and methods were poorly described. Many lacked a clear definition of corruption or a theoretical grounding. Our review and typology highlight trade-offs between rigour, feasibility, and utility. As demand for evidence in this field grows, consensus on corruption definitions and sub-types is needed to guide study design and improve comparability across contexts. Promising directions include theory-informed mixed methods, context-sensitive designs, qualitative pilots, and interdisciplinary approaches.
How to do (or not to do)… asset mapping in community health.
Chen X, Ye E, Fong N … +7 more , Maksud M, Garcia L, Yiu A, Zhou J, Han X, Liao Q, Bishai D
Health Policy Plan · 2026 Mar · PMID 41612796 · Full text
Public health asset mapping involves working in a community partnership to form a systematic inventory of a local community's health-promoting features. Assets include physical amenities such as parks or fitness centers,...
Public health asset mapping involves working in a community partnership to form a systematic inventory of a local community's health-promoting features. Assets include physical amenities such as parks or fitness centers, community clinics, welfare agencies, health-promoting non-governmental organizations, and businesses. A curated list of these resources constitutes an asset map that can be shared to promote better health and better health policies that build on local strengths rather than deficits to address upstream social determinants of health. Procedures for asset mapping must be adapted for local contexts because the identity and focus of assets differ significantly between countries. Asset mapping emerged as an element of an overall approach to asset-based community development (ABCD). However, an expository gap persists between a rich asset-based community development literature and practice-oriented guidance on how to operationalize these processes through coherent asset map design, data collection, analysis, and integration of qualitative insights, especially for the metropolitan context in the public health field. In response, we developed a systematic and replicable five-step guide to systematically map public health assets. Our approach integrates desk research with qualitative insights and produces a structured, evidence-based process for identifying and classifying super-connectors, thereby providing a robust foundation for subsequent knowledge-exchange and implementation. Public health practitioners, researchers, and community leaders can use this guide to identify and mobilize community assets towards co-creating better health policy and better policy implementation.
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